<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_id" data-rule="required" data-source="presentation/index" class="form-control selectpage form-control" name="row[presentation_id]" type="text" value="{$row.presentation_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Test_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-test_date" class="form-control datetimepicker form-control" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[test_date]" type="text" value="{$row.test_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Test_name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-test_name" class="form-control form-control" name="row[test_name]" type="text" value="{$row.test_name}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_version')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_version" class="form-control form-control" name="row[meddra_version]" type="text" value="{$row.meddra_version}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_code" class="form-control form-control  selectpage "
                   data-source="meddra/index" data-show-field="en" data-show-field="en" data-primary-key="code"
                   name="row[meddra_code]" type="text" value="{$row.meddra_code}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Code')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-code" class="form-control selectpicker" name="row[code]">
                {foreach name="codeList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.code"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Value')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-value" class="form-control form-control" name="row[value]" type="text" value="{$row.value}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-unit" class="form-control form-control" name="row[unit]" type="text" value="{$row.unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Result')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-result" class="form-control  form-control" rows="5" name="row[result]" cols="50">{$row.result}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Normal_low_value')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-normal_low_value" class="form-control form-control" name="row[normal_low_value]" type="text" value="{$row.normal_low_value}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Normal_high_value')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-normal_high_value" class="form-control form-control" name="row[normal_high_value]" type="text" value="{$row.normal_high_value}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Comments')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-comments" class="form-control  form-control" rows="5" name="row[comments]" cols="50">{$row.comments}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('More_information')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-more_information" class="form-control selectpicker" name="row[more_information]">
                {foreach name="moreInformationList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.more_information"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
